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Background: Double-contrast upper gastrointestinal barium X-ray radiography (UGI-XR) is the standard gastric cancer screening method in Japan. Atrophic gastritis and enlarged gastric folds are considered the two major features of Helicobacter pylori-induced chronic gastritis, but the clinical meaning of evaluating them by UGI-XR has not been elucidated., Methods: We analyzed healthy UGI-XR examinees without a history of gastrectomy, previous Helicobacter pylori eradication and usage of gastric acid suppressants., Results and Conclusions: Of the 6433 subjects, 1936 (30.1 %) had atrophic gastritis and 1253 (19.5 %) had enlarged gastric folds. During the 3-year prospective observational follow-up, gastric cancer developed in seven subjects, six of whom (85.7 %) had atrophic gastritis with H. pylori infection and five of whom (71.4 %) had enlarged gastric folds with H. pylori infection. The Kaplan-Meier method with log-rank testing revealed that both UGI-XR-based atrophic gastritis (p = 0.0011) and enlarged gastric folds (p = 0.0003) are significant predictors for future gastric cancer incidence.

Background: The prevention of bleeding after endoscopic submucosal dissection (ESD) for gastric neoplasms is still an important problem., Objective: To investigate the efficacy and safety of a shielding method that uses polyglycolic acid (PGA) sheets and fibrin glue to prevent post-ESD bleeding in high-risk patients., Design: A nonrandomized trial with historical control subjects., Setting: A single academic hospital in Japan., Patients: From July 2013 to February 2014, 45 ESD-induced ulcers in 41 patients with a high risk of bleeding were enrolled in a study group. Forty-one consecutive ESD-induced ulcers in 37 control subjects with a high risk of bleeding were treated in 2013 before the first enrollment., Interventions: We placed PGA sheets on the mucosal defect and fixed with fibrin glue in the study group., Main Outcome Measurements: The post-ESD bleeding rate., Results: The post-ESD bleeding occurred at a rate of 6.7% in the study group (3/45 lesions) and 22.0% in the historical control group (9/41 lesions). There was a significant difference in the post-ESD bleeding rate between the 2 groups (P = .041)., Limitations: A nonrandomized trial with historical control subjects; a single-center analysis; small sample size., Conclusions: The endoscopic tissue shielding method with PGA sheets and fibrin glue appears to be promising for the prevention of post-ESD bleeding. (, Clinical Trial Registration Number: UMIN000011058.)., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Full-thickness resection for gastric malignancy carries a risk of peritoneal dissemination due to opening of the gastric lumen. We evaluated the feasibility and safety a novel method of full-thickness resection without transmural communication, called nonexposed endoscopic wall-inversion surgery in ex vivo and in vivo porcine models. Six explanted porcine stomachs and 6 live pigs were used for this study. After marking and submucosal injection around 3 cm simulated lesions, the seromuscular layer was laparoscopically cut and sutured with the lesion inverted to the inside. Consecutively, a mucosubmucosal incision was made endoscopically. Three pigs used for the survival study were monitored for 7 days. All 12 lesions were successfully resected en bloc without perforation. The 3 pigs survived for 1 week without adverse events, and necropsy revealed neither leakage nor abscess formation related to the operation. We demonstrated nonexposed endoscopic wall-inversion surgery to be technically feasible and safe in both ex vivo and in vivo porcine studies.

Background: Certain tumor characteristics may pose challenges when endoscopically determining the horizontal extent of early gastric cancers (EGC). In the present study, clinicopathological features related to inaccurate endoscopic evaluation of horizontal extent of intestinal-type EGC were analyzed., Patients and Methods: We analyzed 431 lesions with intestinal-type EGC treated by endoscopic submucosal dissection (ESD) at our hospital. We focused on whether pretreatment demarcation was accurate by comparing positional relationships between marking dots and tumor edges in resected specimens, and factors related to inaccurate evaluation were analyzed. Gender, age, tumor size, location, circumference, depth, ulceration, macroscopic type, presence of a flat (0-IIb) component, predominant histological type, mixture of diffuse-type adenocarcinoma, mixed histology, and use of magnification endoscopy with narrow band imaging were analyzed. Reasons for inaccurate evaluation were also investigated by re-examining endoscopic images and prepared histological slides., Results: Rate of inaccurate evaluation of horizontal extent was 7.4% (32/431 lesions). Multivariate analysis revealed the following significant independent variables contributing to inaccurate endoscopic evaluation: presence of a flat component, large size, and predominant histological findings of moderately differentiated adenocarcinoma. Re-examination of prepared histological slides of inaccurately evaluated cases revealed a marginal flat spreading area in 28 of the 32 lesions (87.5%). In 14 of the 32 lesions (43.8%), tumor margins were composed of moderately differentiated adenocarcinoma., Conclusions: For lesions with a flat component, large lesions, and moderately differentiated adenocarcinoma, determination of the horizontal extent can be challenging in EGC indicated for ESD, even with the best available endoscopic tools., (© 2013 The Authors. Digestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society.)

Gastric cancer (GC) presents various histological features, though the mechanism underlying its diversity is seldom elucidated. It is mainly classified into well differentiated tubular adenocarcinoma (tub1), moderately differentiated tubular adenocarcinoma (tub2), poorly differentiated adenocarcinoma (por), signet-ring cell carcinoma (sig), mucinous adenocarcinoma (muc), and papillary adenocarcinoma (pap). By screening, we found cathepsin E (CTSE) expresses universally in sig-type, occasionally in por-type, and rarely in tub1/tub2-type GC cell lines. In surgically-resected specimens, CTSE was immunostained in 50/51 sig-type (98.0%), 3/10 tub1-type (30.0%), 7/18 tub2-type (38.9%), 15/26 por-type (57.7%), 4/10 pap-type (40.0%), and 0/3 muc-type (0.0%) GC. In endoscopically-resected specimens, 6/7 sig-type (85.7%), 7/52 tub1-type (13.7%), 5/12 tub2-type (41.7%), 2/7 pap-type (28.6%) GC and 0/6 adenoma (0.0%) expressed CTSE. For non-malignant tissues, CTSE is universally expressed in normal fundic, pyloric, and cardiac glands of stomach, but hardly in other digestive organs. In the precancerous intestinal metaplasia of stomach, CTSE is mostly observed in mixed gastric-and-intestinal type and deficient in solely-intestinal type. CTSE expression is positively correlated with gastric marker MUC5AC (p<0.0001) and negatively correlated with intestinal marker MUC2 (p = 0.0019). For sig-type GC, in both tumors and background mucosa, expression of MUC5AC and CTSE is high whereas that of MUC2 is low, indicating that sig-type GC reflects the features of background mucosa. For gastric adenoma and tub1/tub2-type GC, more undifferentiated tumors tend to show higher expression of CTSE with MUC5AC and lower expression of MUC2 in tumors, but they tend to present lower expression of CTSE, MUC5AC and MUC2 in background mucosa. These suggest that more malignant gastric adenocarcinoma with stronger gastric and weaker intestinal properties tend to arise from background mucosa with decreased both gastric and intestinal features. In conclusion, CTSE is a marker of both gastric differentiation and signet-ring cell carcinoma, which should shed light on the mechanism of gastric tumorigenesis.

Purpose: Evidences on diagnostic ability of esophagogastroduodenoscopy (EGD), CT, and endoscopic ultrasonography (EUS) for gastric submucosal tumor (SMT) are insufficient. For investigating a suitable diagnostic strategy, we retrospectively investigated diagnostic accuracy of EGD and CT for SMT, in comparison to EUS findings., Methods: Ninety-three consecutive lesions in which gastric SMT was suspected by EGD were investigated by EUS from March 2009 to June 2011, including 55 lesions evaluated also by CT 4 months before or after EUS. Frequency of possibly malignant SMTs as a detection rate of EGD, and sensitivity and specificity of CT in detection of SMT were retrospectively analyzed. Factors influencing the ability for CT to detect SMT were also investigated., Results: EUS revealed possibly malignant SMT in 60 cases (64.5%). In 32 out of 55 cases, possibly malignant SMT was suspected by CT. Sensitivity and specificity of CT was 80.6% and 84.2%, respectively. The mean size of possibly malignant SMT detected and not detected by CT was 27.4 and 11.0 mm, respectively, with a statistically significant difference (p = 0.0001)., Conclusion: This study elucidated that approximately one-third of suspected SMTs by EGD might not need clinical care. EUS for suspected SMTs is indispensable for extracting possibly malignant SMTs from others, and CT may be insufficient as an alternative to EUS in detecting especially small ones.

Aim: Endoscopic submucosal dissection (ESD) causes artificial ulcers, and there is no consensus regarding the degree of healing in ESD-induced ulcers or the optimal duration of proton pump inhibitor (PPI) treatment. The aim of the present study was to investigate the healing rates of post-ESD ulcers in response to the protective effect of 2-week PPI treatment., Methods: Between February 2007 and March 2010, 75 patients/75 lesions and 55 patients/55 lesions were enrolled as interim and per-protocol groups, respectively. All patients were prescribed rabeprazole (10 mg/day) orally for 16 days beginning on the day before ESD. Follow-up endoscopy was carried out 8 weeks after ESD to evaluate ulcer healing. The primary end-point was the healing rate of post-ESD ulcers at 8 weeks after ESD. Secondary end-points were the rate of post-ESD bleeding with emergency endoscopy and the rate of other severe adverse effects during the study period., Results: The transitional rate to scarring-stage ulcers was 80.0% (44/55). Location in the lesser curve and large resected size (>40 mm) were statistically significant predictors for delayed ulcer healing by univariate analysis and the latter was still significant by the multivariate analysis. Post-ESD bleeding occurred within 2 weeks in two cases (2.7%), but both cases were successfully managed with endoscopic hemostasis only. Severe adverse effects did not occur., Conclusions: Two-week administration of PPI for post-ESD gastric ulcers may be sufficient to aid healing without increasing any adverse effects in cases where there are no possible deteriorating factors on ulcer healing, although large resection and/or resection in the lesser curve may result in delayed healing even after 8 weeks of ESD., (© 2011 The Authors. Digestive Endoscopy © 2011 Japan Gastroenterological Endoscopy Society.)

Background: The characteristics of stage II gastric cancer according to the Japanese Classification of Gastric Cancer (JCGC) were examined and the high-risk factors predicting poor prognosis were detected., Patients and Methods: In total, 107 patients, who underwent clinically curative gastrectomy with D2 lymphadenectomy for stage II gastric cancer, were included. Survival curves of the depth of invasion, lymph node metastasis, the ratio of involved: resected lymph nodes and chemotherapy treatment were compared., Results: The survival curves were related to tumor invasion depth and lymph node metastasis. The ratio of involved resected lymph nodes was a good prognostic indicator compared to the classification of regional lymph node metastasis (N classification). Survival rates with adjuvant chemotherapy were slightly higher than without adjuvant chemotherapy, but the difference was not significant., Conclusion: pT2pN1 (stage II) gastric cancers according to the JCGC, especially pSSpN1 cases, included stage IIIB and IV gastric cancers according to the International Union Against Cancer / American Joint Committee on Cancer (UICC/AJCC); therefore, the prognosis of these might be poor. With pSSpN1 cases, according to the JCGC, anticancer chemotherapy equivalent to that required for stage III gastric cancer cases is necessary.

The location of a small lesion must be precisely identified during laparoscopic surgery. A gamma probe that is usually used for navigating sentinel lymph nodes was evaluated for its usefulness in locating small gastrointestinal lesions (14 gastric and 10 colonic). A total of 2 mCi of a Tc(99m)-labeled rhenium colloid was injected endoscopically around a tumor 16 h prior to surgery. During operation, the abdominal cavity was scanned using a handheld gamma probe (Navigator GPS, Tyco HealthCare, Norwalk, CT, USA). In all cases, the injection site was identified as the highest spot in the abdominal cavity, with 2585 counts per second on average (range, 910-8800 counts per second). The highest count in a lymph node was 637 per second on average. The gamma probe is a useful tool for identifying small gastrointestinal lesions during open and laparoscopic operations.